UH Med Now
JABSOM Doctor Urges a Pivot from Review of Systems
When we go to the doctor, we often encounter a time-consuming questionnaire that covers all potential ailments from head to toe, even if it’s just the toe prompting the visit.
The tedious questionnaire often contains a review of systems (ROS) that we might have related to other illnesses which could be remotely related to our primary concern. In the latest publication of the Journal of the American Medical Association (JAMA), Dr. Chien-Wen Tseng, MD, MPH at the John A. Burns School of Medicine, urges the medical community to move away from the ROS and embrace a more evidence-based model based upon prior knowledge of the patient and their current presentation.
In establishing the need for change, Tseng and co-author Michael Barry, MD, from Massachusetts General Hospital in Boston, revisit the creation of the ROS.
The authors explain that doctors keep meticulous medical records to ensure a continuity of care between physicians. Ideally, a patient’s file should be passed from one doctor to another, with each getting a good sense of the patient’s health background. Well-kept records can also make medical care transparent to patients.
While Tseng and Barry demonstrate the need for thorough record-keeping, they acknowledge that billing and coding requirements have driven documentation more than ever before. “For decades, clinicians were reimbursed at a higher level by the Centers for Medicare & Medicaid Services (CMS) if visits included an ROS.” Often the ROS would contain extraneous information and be unrelated to the patient’s medical condition.
Tseng and Barry write, “these financial incentives (to document unrelated ROS information) [have] linked tradition-based care with reimbursement-based care, [resulting in] care documented largely for billing requirements. Although it was meant to improve care, performing and documenting completion of the ROS lacked evidence for benefit and inadvertently risked some harm.”
The authors explain that patients who genuinely take the time to answer the ROS can sometimes be honest to a fault. “Virtually all patients may have an innocuous change in bowel habits, a common ROS question, from time to time,” Tseng and Barry write. “This type of screening can unintentionally lead to an expensive or even risky workup of nonproblematic symptoms.”
The ROS is described as a time-waster. Tseng and Barry say the questionnaires take up precious time that could be dedicated to addressing the patient’s real reason for their visit and other health problems that could be more specific to their backgrounds and pre-determined risk factors.
It would seem that the Centers for Medicare & Medicaid Services agree with Drs. Tseng and Barry because in 2021, the previously detailed documentation requirements, including the need for the ROS, were replaced with “visits reimbursed based on the complexity of medical decision-making or total clinician time spent.”
Unfortunately, 18 months later, ROS questionnaires are still a big part of a regular visit to the doctor.
In the September 30th issue of JAMA, Tseng and Barry offer alternatives that ultimately would make a doctor’s visit more interactive.
Tseng and Barry urge medical providers to move toward evidence-based care, which includes deeper conversations with patients.
“Face-to-face time between primary care clinicians and patients is precious and deserves to be spent effectively to improve patients’ health, including building relationships that facilitate care and improve outcomes going forward,” write Tseng and Barry.
Using the US Preventive Services Task Force (USPSTF) recommendations as a guide, the authors suggest counseling replace the time spent filling out and documenting the ROS questionnaires.
“Rather than obtaining information from an ROS, more time might well be spent on counseling activities when evidence indicates that lifestyle change counseling can meaningfully reduce adverse health outcomes,” write Tseng and Barry.
In other cases, the authors suggest doctors make time for shared decision-making. It’s a method that Tseng and Barry say has been pushed aside by the ROS.
“With shared decision-making, patients and clinicians discuss different options, including their benefits and harms, and consider patients’ values and preferences in reaching a decision together. The USPSTF has emphasized the importance of shared decision-making for preventive care, which has been shown to improve the quality of medical decisions and increase patient engagement.”
Steering physicians away from the ROS which many physicians were taught as “gospel” may take time, but JABSOM Dean Jerris Hedges strongly endorses the change.
“The commentary provided by Drs. Tseng and Barry could signal a fundamental change in the delivery of medicine,” he says.
“It critiques an archaic documentation practice which burns time for all providers. Making the recommended change, especially knowing that CMS reimbursement supports more meaningful physician patient communication signals opportunity for a reduction in the administrative burden of physician practice. As unnecessary documentation distracts from the delivery of care and slowly erodes the practice enjoyment of physicians and other providers, this is a huge paradigm shift,” he says.
To read Dr. Tseng’s full commentary in JAMA, click here: https://jamanetwork.com/journals/jama/fullarticle/2797134
Dr. Tseng has also served on the US Preventive Services Task Force (USPSTF) since 2016. USPSTF recommendations have made a positive impact on millions of Americans, covering a wide range of areas. For a comprehensive look at Dr. Tseng’s work on the USPSTF, click here: https://jabsom.hawaii.edu/jabsoms-chien-wen-tseng-the-us-preventive-task-force/
Matthew Campbell, Director of Communications